Kimberly Michelle Swanson
Abstract: Uncertainty and Futility in the Intensive Care Unit
An estimated 90% of deaths occurring in intensive care units (ICU) are due to a decision to withhold or withdraw life support (Way, Back, & Curtis, 2002). In each individual case, the clinician, family, and surrogate decision maker must come together and confront the decision about whether to pursue continued treatment aimed at prolonging life. As health care providers, our responsibility is to care for families who are making this difficult decision. It is imperative, therefore, that nurses be knowledgeable regarding what factors families consider important in determining the futility of a treatment. The purpose of this paper is to explore this question: What factors do families consider important when making a decision to withdraw or withhold treatment from a loved one? The review of literature found that family's decision making fell within four domains: emotional/moral factors, medical factors, cultural factors, and economic/legal factors.
In order to guide nursing practice in the care of families experiencing this difficult time, Mishel's theory of Uncertainty in Illness was utilized to gain a more in-depth understanding of the indecision that families often struggle with when making end-of-life decisions regarding futility. This middle range nursing theory was applicable because of the congruency between the concepts of uncertainty and futility found in this model. Also, many of the emotional, medical, legal/financial, and cultural decision-making factors found in the review of literature matched definitions of important concepts contained in the theory. This model offers an explanation of futility and its effects on uncertainty.
The resulting nursing implications revolved around the pertinent issues of communication, advocacy, and nursing education. Open and balanced communication between family and the health care team is often central to decreasing uncertainty involving end-of-life decisions (Bowman, 2000; Mishel, 1988). In addition, nursing advocacy fosters trust and social support that results in decreased uncertainty. This review also reveals its limitations and makes suggestions for future research.
